Provider Demographics
NPI:1245269273
Name:SAFEWAY INC
Entity type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:623-869-3524
Mailing Address - Street 1:PO BOX 60000 FILE 74150
Mailing Address - Street 2:
Mailing Address - City:SAN FRANSISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94160-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1632 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2302
Practice Address - Country:US
Practice Address - Phone:856-470-1213
Practice Address - Fax:856-470-1205
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAFEWAY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-02
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00623500332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
3145237OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NJ9107509Medicaid
NJP0022891Medicare PIN
3145237OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NJPHC085Medicare PIN